MEDICARE: MRS. ELISSA SUZANNE DRAKE LDEM, CPM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	176B00000X	Midwife	6225016-3400	UT

General Provider Information

NPI Number	:	1033891791
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ELISSA SUZANNE DRAKE LDEM, CPM

Provider Business Mailing Address
First Line	:	703 N 1050 W
Second Line	:
City	:	CLEARFIELD
State	:	UT
Zip	:	84015-9331
Country	:	US
Telephone Number	:	801-686-0154
Fax Number	:

Provider Business Practice Location Address
First Line	:	1660 W ANTELOPE DR
Second Line	:
City	:	LAYTON
State	:	UT
Zip	:	84041-1156
Country	:	US
Telephone Number	:	801-917-6104
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/02/2023
Last Update Date	:	08/02/2023

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